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Best Practices for Constructing High-Quality Patient Instructions (Sig) Within E-Prescriptions

(Last Updated On: September 5, 2017)

*Originally published by Surescripts

Purpose: To provide guidance and best practices to EHR technology partners and their end-users on creating high-quality prescription directions.

Description: The National Council for Prescription Drug Programs (NCPDP) SCRIPT Version 10.6 allows the transmission of patient directions within the Directions field of a new electronic prescription. This Directions field is intended to convey the prescriber’s instructions for using or administering the medication/therapy assigned and can accommodate up to 140-alphanumeric characters.

Ensuring that the instructions provided by the prescriber are complete, unambiguous, and non-contradictory is critically important for ensuring that the prescription is processed accurately and in accordance with the prescriber’s intent.

Below are best practices that have been developed to assist in the construction of complete, non-contradictory, and clear patient directions:

Ensure that Directions are complete and accurate
• All information in the Sig must be accurate, complete, and include all the required components written in the following order: action, dose, dose units, route, frequency, and finally auxiliary information.

o The exception to this syntax is Sigs which simply state “Take/Use as Directed/Instructed as per manufacturer labeling.”

• Information within the Sig must not conflict with itself

Example: Use “Take 1 tablet by mouth daily” instead of just “Daily.”

Always qualify “…as Directed” with a source
• Statements such as “Take as directed” and “Use as instructed” should only be used when followed by a source that clearly dictates to the patient where or from whom they can obtain the specific directions.
• If a Sig builder tool is used, ensure that prescribers enter the specific source of the instruction after selecting the “Take/Use as directed/instructed” option before they can proceed with finalizing the e-prescription.

Example: Use “Use as instructed per instructions on package” instead of “Use as instructed.”

Always qualify “PRN (as needed)” with an indication
• The use of “PRN” (i.e. “as needed”) should only be used in conjunction with an indication.
• For all other non-PRN directions, inclusion of an indication is also recommended; alternatively, there is also a designated structured field for Diagnosis, in which ICD-10 codes may be used to communicate the appropriate diagnosis or indication relevant for the prescribed product
• If a Sig builder tool is used, ensure that the Sig builder tool requires prescribers to enter the specific indication or conditions for PRN use if the prescriber selects a “PRN” frequency

Example: Use “Take 1 tablet by mouth every 4 hours as needed for mild to moderate pain” instead of “Take 1 tablet by mouth every 4 hours as needed.”

Always specify the Duration of Therapy for Acute Treatments
• Duration of therapy should only be specified for medications for acute treatments with a defined length of therapy, e.g., antibiotics.

Avoid Abbreviations, Acronyms or Symbols
• ISMP (Institute for Safe Medication Practices) provides the complete list of Error-Prone Abbreviations, Symbols, and Dose Designations that should never be used in a prescription
• If the use of Latin abbreviations is desired, the system should include the ability to expand Latin abbreviations into plain English text via keystroke accelerators. The expanded text form of the Sig should be displayed to the prescriber to ensure correct transition from abbreviations to full text

Example: Use “Instill 1 drop into both eyes once daily” instead of “1 gtt ou qd.”

Never Truncate or Split Directions between multiple fields
• If the patient directions are being transmitted exceeds the 140-character limit, it should be communicated by other means, e.g. as a fax or printed handout
• Sig information should not be written into the Notes field if it exceeds the 140-character limit.

Send only Patient Directions (Sig) within the Directions field
• The Sig should not contain information for which another designated field exists in the SCRIPT standard (e.g. the Sig should never include the quantity, drug name, NDC or RxCUI values, or Notes to pharmacists, etc.)

Example: Use “Take 1 tablet by mouth once daily” instead of “Take 1 tablet by mouth once daily. Dispense #30, 3 Refills, Thank you.”

Call to Action
• For additional information, kindly access the updated Surescripts Guidelines document here
Prescriber Training – Please leverage these best practices to enhance end-user training documents/materials to promote accurate and complete patient directions being transmitted within e-prescriptions
Software/UI Enhancements – Please also update and develop software and/or user interface (UI) enhancements to ensure accurate and complete patient directions are transmitted within e-prescriptions

For additional information or to learn more about the Surescripts Quality Management Program please contact Surescripts Quality Management at quality@surescripts.com.

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